ACCIDENT INVESTIGATION BASICS

WHAT YOU WILL LEARNWhat is an incident? What is an accident?

Why should you investigate both?

How should you investigate?

What results are you looking for?

What are you required to do for a WISHA investigation?

What Is An Incident? Unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property.An incident disrupts the work process, does not result in injury or damage, but should be looked as a wake up call. It can be thought of as the first of a series of events which could lead to a situation in which harm or damage occurs. Employers should investigate an incident to determine the root cause and use the information to stop process and behaviors that could just as easily have resulted in an accident.

Example of an incident:: A 50 lb carton falls off the top shelf of a 12 high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

What Is An Accident?Unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people. Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.

What Is An Accident?An accident is not just one of those things.

Accidents are predictable and preventable events.

They dont have to happen.Most workplace injuries and illness are not due to accidents. The term accident is defined as an unexpected or unintentional event, that it was just bad luck. More often than not it is a predictable or foreseeable eventuality.By accidents we mean events where employees are killed, maimed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, etc).A systematic plan and follow through of investigating incidents or mishaps and altering behaviors can help stop a future accident. Lets take the 50 lb carton falling 12, for the 2nd time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to solution to prevent it from falling in the future.

The Tip of the IcebergDont just investigate accidents. Incidents should also be reported and investigated. They were in a sense, aborted accidents.Criteria for investigating an incident: What is reasonably the worst outcome, equipment damage, or injury to the worker? What might the severity of the worst outcome have been? If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an actual accident investigation.The 50 pound carton falls off the top shelf of a 12 high rack and lands near a worker. The outcome of an investigation might include correction of sloppy storage at several locations in the warehouse, unstable/heavy items will be stored at floor level if possible, refresher training of stockers on proper methods is done, supervisor begins doing daily checks.Accidents or injuries are the tip of the iceberg of hazardsInvestigate incidents since they are potential accidents in progressAccidentsIncidents

What is an Accident?By dictionary definition: an unforeseen event, .chance.., unexpected happening.., formerly Act of GodHazardous conditionsClose callsMinor injuriesSevere InjuriesFatalities From experience and analysis: they are caused occurrences Predictable - the logical outcome of hazards Preventable and avoidable - hazards do not have to exist. They are caused by things people do -- or fail to do.

Why Investigate?Prevent future incidents (leading to accidents).

Identify and eliminate hazards.

Expose deficiencies in process and/or equipment.

You lose money when regular work stops.

Maintain worker morale.

The rule requires you to investigate serious accidents.

How To InvestigateDevelop a plan

The next 6 slides will outline each component you need for effective Accident Investigation. Then we will look into each component in more detail.The time to develop your companys Accident Investigation Plan is before you have an incident or an accident.The who, when, where, what and how should be developed before the incident.Accident Investigation Training, investigation tools and your policies and procedures should be developed before the incident or accident.One size will not fit all. Your companys motor vehicle investigation reports will differ from your warehouse investigations, as will your off-site investigations.

How To InvestigateAssemble an investigation kit Investigate all incidents and accidents immediately Collect factsIt is important to begin your investigation immediately. Evidence disappears, the 50 lb carton of material was cleaned up and memory fadesthe employee was not encouraged to report the near-miss incident and forgot about the whole thing.When investigating incidents or accidents be thorough in your capture of all available facts. You might discover that many other items were also improperly stored and that when employees were questioned there had been several other near misses

How To InvestigateInterview witnessesInterview witnesses and victims in a timely manner. LISTENDont blame, dont point out poor judgment, be sympatheticLISTENIf you know for a fact that someone broke a rule it is not important to point that out to them at this time. Verify with them the training they have received and ask them if they know what happened to cause the accident. Again, it doesnt do anyone any good at this juncture to be told it was your fault or you knew better

As an investigator, you will often come to the conclusion that someone engaged in an unsafe act. It is most important to determine why they engaged in an unsafe act as well as verify that they did or did not know better.

How To InvestigateWrite a report

The report should include: An accurate narrative of what happenedClear description of unsafe ACT or CONDITIONRecommended immediate corrective actionRecommended long-term corrective actionRecommended follow up to assure fix is in placeRecommended review to assure correction is effective.

Tips for Developing A PlanDevelop your action plan ahead of time.Your plan might include:Who to notify in the workplace?How to notify outside agencies?Who will conduct the internal investigation?Preplanning will help you address situations timely, reducing the chance for evidence to be lost and witnesses to forget. All procedures, forms, notifications, etc. need to be listed out as step-by-step procedures. You might wish to develop a flow chart to quickly show the major components of your program.

Develop a Plan Tips (continued)What level of training is needed?Who receives report?Who decides what corrections will be taken and when?Who writes report and performs follow up?

Some expansion questions on the above points are:Who will be trained to investigate?Who is responsible for the finished report and what is the time frame?Who receives copies of the report?Who determines which of the recommendations will be implemented?Who is responsible for implementing the recommendations? Who goes back and assures that fixes are in place?Who assures that fixes are effective?

What Should Be In The Investigation Kit Camera equipment First aid kitTape recorder GlovesTape measure Large envelopesHigh visibility tape Report formsScissorsGraph paperScotch tape Sample containers with labelsPersonal protective equipment

These are some common items for a kit. What else might be useful? Anything from your specific business or workplace that might be needed?

Investigate All Incidents/AccidentsConduct and document an investigation that answers:Who was present? What activities were occurring?What happened?Where and what time?Why did it happen?

Root causes should be determined. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling.

Investigate All Incidents/AccidentsAlso answer:Is this a company or industry-recognized hazard?Has the company taken previous action to control this hazard? What are those actions?Is this a training issue?Link to sample accident investigation form

Begin Investigations ImmediatelyIts crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

How Do You Investigate?Notify individuals according to your plan

You must involve an employee representative, the immediate supervisor, and other people with knowledge

Grab your investigation kit

Approach the scene

Actions At The Accident SceneCheck for danger

Help the injured

Secure the scene

Identify and separate witnesses

Gather the facts

First, make sure you and others dont become victims! Always check for still-present dangerous situations. Then, help the injured as necessary.Secure the scene and initiate chains of custody for physical evidence.Identify witnesses and physical evidence. Separate witnesses from one anotherIf physical evidence is stabilized, then begin as quickly as possible with interviews.REMEMBER, BE A GOOD LISTENER

Fact FindingWitnesses and physical evidence

Employees/other witnesses

Position of tools and equipment

Equipment operation logs, charts, records

Equipment identification numbers

Fact FindingTake notes on environmental conditions, air quality Take samplesNote housekeeping and general working environmentNote floor or surface conditionTake many picturesDraw the sceneSome scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance. Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation?Consider creating a photo log. The log should describe the date, time, give a description of what is captured in the photo and directionality. Link to sketch of accident scene.

Interview WitnessesLISTEN

Dont blame, just get facts

Talk to witnesses as equals

Keep conversations informal

Interview WitnessesChoose a private place to talkAsk open ended questionsInterview promptly after the incidentAsk some questions you know the answers to

Your method and outcome of interview should include: who is to be interviewed first; who is credible; who can corroborate information you know is accurate; how to ascertain the truth bases on a limitation of numbers of witnesses. Be respectful, are you the best person to conduct the interview?If the issue is highly technical consider a specialist, this may be an internal resource or it may be an outside resource.

Write The Report How and why did the accident happen?A list of suspected causes and human actionsUse information gathered from sketches, photographs, physical evidence, witness statementsRemember that your report needs to be based on facts. All recommendations should be based on accurate documented findings of facts and all findings and recommendations should be from verifiable sources.

Write The Report When and where did the accident happen?

What was the sequence of events?

Who was involved?

What injuries occurred or what equipment was damaged?

How were the employees injured?Answer the following in the report:

Report ConclusionsWhat should happen to prevent future accidents?What resources are needed?Who is responsible for making changes? Who will follow up and insure implementation of corrections?

What will be future long-term procedures?Conclusions must always be based upon facts found during your investigation. If additional resources are needed during the implementation of recommendations then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.

When Accidents Occur, What Is Required By L&I?WAC 296-800-32005 Report a death or hospitalization to L & I with specific information

WAC 296-800-32010 Do not move equipment

WAC 296-800-32015 Assign people to assist L & I investigators

WAC 296-800-32020 For all serious injuries conduct a preliminary investigationThere are four specific requirements:Link to these rules

Report A Death or Hospitalization (Catastrophe)Report the death, probable death, or the in-patient hospitalization of 2 or more employees within 8 hours to:Labor and Industries, 1-800-4BE-SAFEWAC 296-800-32005The required information that must be provided to L&I:1- Name of the work place2- Location of the incident3- Time and date of the incident4- Number of fatalities or hospitalized employees5- Contact person6- Phone number7- Brief description of the incident

Do Not Move EquipmentIF: A death or probable death happens or two or more employees are admitted to the hospital

THEN: You must not move any equipment until L&I says you can

UNLESS: You must move the equipment to remove victims or prevent further injuryWAC 296-800-32010

Assign People to Assist L&IInclude the immediate supervisor of victim, andEmployees who witnessed the accident, andOther employees L&I feels are necessary

WAC 296-800-32015

Conduct a Preliminary InvestigationWAC 296-800-32020Evaluate facts relating to cause of accident by following people:Person assigned by employerImmediate supervisor of injured employeeWitnessesEmployee representativeAny other person who has the experience and skills(Required for all serious injuries)

Conduct a Preliminary InvestigationIf employee rep is union agent and is unavailable you may use:Shop steward, orEmployee rep on safety committee, orPerson selected by all employeesWAC 296-800-32025Document your findings

What You LearnedIncident vs. AccidentWhat investigations do for youMechanics of investigatingThe rules

Need further help? Safety & health program review and worksite evaluationBy employer invitation onlyFreeConfidentialNo citations No penaltiesLetter explains findingsFollow-up all serious hazards

WISHA Consultation Services offers

Welcome: Instructor IntroductionRegistration/Attendance RosterAudience fills out name placardsHandouts (Initial)Workshop slides/Notes Consultation Services Pamphlet Evaluation FormFeel free to ask questions as we go.Introductions -- name, business, expectations for the class Purpose: To assist you in understanding the importance of investigating both incidents and accidents, so that changes are made which prevent future mishaps.

Invite participants to think about the difference between incident and accident. Tell them to think about it because we will talk about it later.

For the bullet: What RESULTS are you looking for: This would include removing or minimizing the potential for another occurrence. To seek to minimize the pain and suffering, equipment damage, loss of morale. Empower employees by having a system to address unsafe conditions or acts before other or more serious injuries occur

As part of the bullet on WISHA requirements wee will discuss:When are you required to notify LNI?When are you required to conduct an investigation?What is required to be in the investigation?

An incident disrupts the work process, does not result in injury or damage, but should be looked as a wake up call. Could be thought of as the first of a series of events which could lead to a situation in which harm or damage occurs. Employers should investigate an incident to determine the root cause and use the information to stop process and behaviors that could just as easily have resulted in an accident.Example of an incident: A 50 lb carton falls off the top shelf of a 12 high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

Ask audience for example of a real incident that has occurred at their workplace. Then say: We will discuss why a policy that encourages resolution of incidents, near-misses, will be worth the time and effort.

Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.Most workplace injuries and illness are not due to accidents. The term accident is defined as an unexpected or unintentional event, that it was just bad luck. More often than not it is a predictable or foreseeable eventuality.By accidents we mean events where employees are killed, maimed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, Hantavirus etc). A systematic plan and follow through of investigating incidents or mishaps and altering behaviors can help stop a future accident. Lets take our mythical 50 lb carton falling 12, for the 2nd time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes.Ask audience to give examples of both incidents and accidents, using the definitions presented.

Bullets will appear upon mouse click.If time: Ask audience: Any other reasons to investigate? The next 6 slides will outline each component you need for effective Accident Investigation. Then we will look into each component in more detail.

The time to develop your Companys Accident Investigation Plan is before you have an incident or an accident.The who, when, where, what and how should be developed before the incident.

Accident Investigation Training, investigation tools and your policies and procedures should be developed before the incident or accident.

One size will not fit all. Your Companys motor vehicle investigation reports will differ from your warehouse investigations as will your off-site investigations.

There will be some standard kit items, which we will discuss later. Each of you might have some custom items particular to your operation.Whole books and special training sessions have been given on interviewing witnesses. Well cover the highlights.Some things to think about right now:Interview witnesses and victims in a timely manner. LISTENDont blame, dont point out poor judgment, be sympatheticLISTENIf you know for a fact that someone broke a rule it is not important to point that out to them at this time. Verify with them the training they have received and ask them if they know what happened to cause the accident. Again, it doesnt do anyone any good at this juncture to be told it was your fault or you knew better

As an investigator, you will often come to the conclusion that someone engaged in an unsafe act. It is most important to determine why they engaged in an unsafe act as well as verify that they did or did not know better.Is knowing better the same as being trained to perform a task in a safe manner? It important to define that knowing better was because they were trained and took a short cut as opposed to knowing better because its common sense not to do it that way.Incident and Accident reports are a compilation of facts.

They include: Writing an accurate narrative of what happenedClear description of unsafe ACT or CONDITIONRecommended immediate corrective actionRecommended long-term corrective actionRecommended follow up to assure fix is in placeRecommended review to assure correction is effective.The majority of the rest of this presentation will expand on the six points we just covered about how to investigate accidents and incidents.Bullets will appear upon mouse click.Preplanning will help you address situations timely, reducing the chance for evidence to be lost and witnesses to forget. All procedures, forms, notifications, etc. need to be listed out as step-by-step procedures. You might wish to develop a flow chart to quickly show the major components of your program.Bullets will appear upon mouse click.

The plan will provide instructions on actions to be taken by key people in your business, assigning roles and responsibilities.Some expansion questions on the above points are:Who will be trained to investigate?Who is responsible for the finished report and what is the time frame?Who receives copies of the report?Who determines which of the the recommendations will be implemented?Who is responsible for implementing the recommendations? Safety, Training, Operations?Who goes back and assures that fixes are in place?Who assures that fixes are effective?

These are some common items for a kit. What else might be useful? Anything from specific types of businesses that might be needed?Bullets will appear upon mouse click.Briefly discuss the concept of root causes. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling.Bullets will appear upon mouse click.Links: Two examples are given of Reports, and one of a ChecklistThis statement is true for both near-misses, mishaps (incidents) as well as accidents in which injuries or illnesses have resulted.Bullets will appear upon mouse click.First, make sure you and others dont become victims! Always check for still-present dangerous situations.Then, help the injured as necessarySecure the scene and initiate chains of custody for physical evidenceIdentify witnesses and physical evidenceSeparate witnesses from one anotherIf physical evidence is stabilized, then begin as quickly as possible with interviewsREMEMBER, BE A GOOD LISTENERBullets will appear upon mouse click.This slide and the next will show what you should take notes on at the accident or incident scene. Have discussion with the audience on each point as it appears. Bullets will appear upon mouse click.Some scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance.Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation?Consider creating a photo log. The log should describe the date, time, give a description of what is captured in the photo and directionality. Example: Photo # 4, February 1, 2004, 10:36 AM, Northeast corner of Warehouse Number 2, Row 11, Bin 14, showing carton that fell from top shelf. Note: crushed bottom corner of carton and wet area under carton on floor. Link to sketch of bakery accident scene: Tell the audience how much information can be captured through a simple line drawing using stick figures. They dont need to be an artist.

Have audience react to each point and tell why they think they might or might not be important.Your method and outcome of interview should include: who is to be interviewed first; who is credible; who can corroborate information you know is accurate; how to ascertain the truth bases on a limitation of numbers of witnesses. Be respectful, are you the best person to conduct the interview?If the issue is highly technical consider a specialist, this may be an internal resource or it may be an outside resource.

Remember that your report needs to be based on facts. All recommendations should be based on accurate documented findings of facts and all findings and recommendations should be from verifiable sources.

A timeline or chronological narrative is sometimes helpful.Conclusions must always be based upon facts found during your investigation. If additional resources are needed during the implementation of recommendations then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.

Bullets will appear upon mouse click.The four rules outlined to emphasize that there are actual WAC rule requirements.Review the required information that must be provided to L&I:1- Name of the work place2- Location of the incident3- Time and date of the incident4- Number of fatalities or hospitalized employees5- Contact person6- Phone number7- Brief description of the incident

Bullets will appear upon mouse click.Having a plan in place allows you to document the scene, identify witnesses, and establish a chain of custody for physical evidence.Having an Accident Investigation Plan in place allows for an organized systematic approach and lends to the appearance of a structured, thought out program.What is a serious injury? There is no definition in the rule. The employer is left to make that determination. Certainly medical treatment beyond first aid. Points to discuss with the audience: Did the accident produce an acute or chronic injury, is it recordable on the OSHA 300, what about loss time, restrictions or transfer?

You must allow labor to participate in the investigation.You must keep written records of your investigation.In Summary:Have the audience describe:The difference between an incident and an accidentWhy investigating them is beneficialThe basic points of doing an investigationWhat the rules require.

A comprehensive consultation visit will lower but not remove your businesss name from the current cycle of scheduled compliance inspections but will not exempt you from:imminent dangerfatalityaccidentcomplaint/referral inspections by complianceComprehensive consultation means a review of injury data, all written safety programs, physical walk through of the entire workplace, written report to the employer and confirmation of correction of all serious hazards identified.